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Rech MA, Donahey E, DeMott JM, Coles LL, Peksa GD. The impact of antihypertensive use in the treatment of acute ischemic stroke in patients receiving alteplase. Am J Emerg Med 2021; 50:93-96. [PMID: 34329955 DOI: 10.1016/j.ajem.2021.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treatment of acute ischemic stroke (AIS) with intravenous alteplase within 4.5 h of symptom onset is associated with neurologic improvement. High baseline blood pressure (BP) and BP variability during the first 24 h of AIS is associated with increased early adverse events and death. The purpose of this study is to characterize the incidence of poor neurologic outcome in patients treated with alteplase for AIS who received antihypertensive medications prior to and within the first 24 h following alteplase administration compared with patients who did not. METHODS This was a multicenter, retrospective cohort of patients >18 years diagnosed with AIS from January 1, 2011 through December 31, 2015 who received one or more antihypertensive medication in the first 24 h of AIS in patients receiving alteplase compared to controls. The primary endpoint was poor neurologic outcome at 90 days, according to modified Rankin Scale ≥3. Univariate analysis was conducted using Chi-square, Fisher's exact test, or Mann-Whitney U test. Multivariable logistic regression was conducted to determine independent predictors of poor outcome. RESULTS Of the 587 patients evaluated, 351 (59.7%) were included, of which 127 (36.2%) received antihypertensive(s). More patients in the antihypertensive treatment group had a history of hypertension (88.2% vs. 69.6%, p < 0.01), diabetes (37% vs. 25.5%, p = 0.03) and chronic kidney disease (19.7% vs. 8.5%, p < 0.01). Intravenous push labetalol was most commonly administered (81.2%), followed by nicardipine (44.1%), and hydralazine (22%). More patients in the antihypertensive treatment group experienced poor neurologic outcome at 90 days (53.5% vs. 38.8%, p < 0.01), however, this finding was not observed after multivariable logistic regression. CONCLUSION Antihypertensive treatment in the first 24 h of AIS was associated with poor neurologic outcomes at 90 days. However, after controlling for other clinical factors in a multivariable logistic regression, this association was no longer observed.
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Affiliation(s)
- Megan A Rech
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL 60153, United States of America.
| | - Elisabeth Donahey
- Department of Pharmacy, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States of America.
| | - Joshua M DeMott
- Rush University Medical Center, Chicago IL, 1653 W Congress Pkwy, Chicago, IL 60612, United States of America.
| | - Laura L Coles
- Novant Health Forsyth Medical Center, 3333 Silas Creek Pkwy, Winston-Salem, NC 27103, United States of America
| | - Gary D Peksa
- Rush University Medical Center, Chicago IL, 1653 W Congress Pkwy, Chicago, IL 60612, United States of America.
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Liu C, Xie J, Sun S, Li H, Li T, Jiang C, Chen X, Wang J, Le A, Wang J, Li Z, Wang J, Wang W. Hemorrhagic Transformation After Tissue Plasminogen Activator Treatment in Acute Ischemic Stroke. Cell Mol Neurobiol 2020; 42:621-646. [PMID: 33125600 DOI: 10.1007/s10571-020-00985-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/22/2020] [Indexed: 12/17/2022]
Abstract
Hemorrhagic transformation (HT) is a common complication after thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) in ischemic stroke. In this article, recent research progress of HT in vivo and in vitro studies was reviewed. We have discussed new potential mechanisms and possible experimental models of HT development, as well as possible biomarkers and treatment methods. Meanwhile, we compared and analyzed rodent models, large animal models and in vitro BBB models of HT, and the limitations of these models were discussed. The molecular mechanism of HT was investigated in terms of BBB disruption, rt-PA neurotoxicity and the effect of neuroinflammation, matrix metalloproteinases, reactive oxygen species. The clinical features to predict HT were represented including blood biomarkers and clinical factors. Recent progress in neuroprotective strategies to improve HT after stroke treated with rt-PA is outlined. Further efforts need to be made to reduce the risk of HT after rt-PA therapy and improve the clinical prognosis of patients with ischemic stroke.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Shanshan Sun
- Department of Ultrasound Imaging, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Xuemei Chen
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Junmin Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China
| | - Anh Le
- Washington University in St. Louis, Saint Louis, MO, 63130, USA
| | - Jiarui Wang
- The Johns Hopkins University, Baltimore, MD, 21218, USA
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Jian Wang
- Department of Anatomy, College of Basic Medical Sciences, Zhengzhou University, Henan, 450000, People's Republic of China.
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China.
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Abstract
PURPOSE OF REVIEW Elevations in systolic blood pressure (BP) greater than 140 mmHg are reported in the majority (75%) of patients with acute ischemic stroke and in 80% of patients with acute intracerebral hemorrhages (ICH). This paper summarizes and updates the current knowledge regarding the proper management strategy for elevated BP in patients with acute stroke. Recent studies have generally showed a neutral effect of BP reduction on clinical outcomes among acute ischemic stroke patients. Thus, because of the lack of convincing evidence from clinical trials, aggressive BP reduction in patients presenting with acute ischemic stroke is currently not recommended. Although in patients treated with intravenous tissue plasminogen activator, guidelines are recommending BP < 180/105 mmHg but currently, the optimal BP management after reperfusion therapy still remains unclear. In acute ICH, the evidence from randomized clinical trials supports the immediate BP lowering targeting systolic BP to 140 mmHg, which is now recommended by guidelines.
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